All Branch Topic (ABT) How many patients do you see?

[Perrotfish]

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For the clinic docs on here, current and former, how many patients are you seeing in a day? How many Tcons? My clinic is arguing over what a reasonable schedule is.

 

[TurtleDO2012]

For primary care I think the average is 85 patients a week and the goal is to get it up to 90 patients a week. Airforce is 90 patients a week. My clinic does 20 min appointments, 1 hr of lunch which is really 30 min or less since everything runs late. I think their is one "tcon/relay health" slot in morning and afternoon. One afternoon a week is clinic meeting/training/admin/caught up on Tcons and relay health.
Clinic has now adopted a policy where no patient will be turned away so it's a waiting game putting them last of the morning or last of the day and hope they just follow up at next opening.

See what the clinic goal is. Is it access or RVU generated? If access then you are screwed but if they can compromise maybe u can squeeze in various physicals and PHAs in 30 min appointments since these visits are worth more than typical appointment.

 

[HighPriest]

Currently, I see 25-30/full day. But I operate two days/week, and it's a subspecialty clinic. At my last duty station I saw 30-40/day, but I operated three days/week and my PA saw about 15-20/day five days/week.

 

[Chonal Atresia]

Is this strictly an AD question? I'm with HighPriest. I am a surgical subspecialist and would see 25-30 while on active duty. I have been in private practice for the last two years and will typically schedule 50-55/day if the volume is there. Usually 40-45 actually show up.

This is a big reason why, IMO, socialized medicine can never work in this country. You can't change human nature. If you pay someone a set salary no matter the volume of patients they see, do you really think that physician is going to go the extra mile? If the pay is the same for 25 vs 50 patients, what do you think is going to happen?

I'll get off my soapbox now.

 

[HighPriest]

Well, we can just replace MDs with NPs! Like the one that spent 4 months putting bacitracin on the enlarging, ulcerated, fungating scalp mass I just saw on a guy who ended up having regionally metastatic skin cancer - what a coincidence!!!

 

[HighPriest]

I think it's also important, when comparing military numbers to private practice, that my office hours are 8:00-ish to 11:30 and 13:00-14:30-ish. This is not by my choice. My staff starts checking patients in about 08:20 even if the patient shows up at 07:45. My last scheduled patient is 14:20, and I have to actually ask my front desk staff to be available after that time if someone comes up from the ER. They usually start shutting off the room lights around 13:30. From my experience, there is no 8 hour shift in any office in the Army. Do I end up seeing patients over lunch? All the time, but I'm usually on my own save for 1-2 good techs who would stick around n questions asked if I needed them. If I was seeing clinic 07:30-12:00 and 13:00-17:00 with a scribe and good MSAs who had any interest in taking a good history or doing a med recon, I could do twice as much work. Not to mention AHLTA, but we all feel the same way about that.

I realize that we're only expected to be 3/4ths of a provider in the military, but based upon the tools we have available to us, I think that's still a stretch.

 

[Chonal Atresia]

I think it's also important, when comparing military numbers to private practice, that my office hours are 8:00-ish to 11:30 and 13:00-14:30-ish. This is not by my choice. My staff starts checking patients in about 08:20 even if the patient shows up at 07:45. My last scheduled patient is 14:20, and I have to actually ask my front desk staff to be available after that time if someone comes up from the ER. They usually start shutting off the room lights around 13:30. From my experience, there is no 8 hour shift in any office in the Army. Do I end up seeing patients over lunch? All the time, but I'm usually on my own save for 1-2 good techs who would stick around n questions asked if I needed them. If I was seeing clinic 07:30-12:00 and 13:00-17:00 with a scribe and good MSAs who had any interest in taking a good history or doing a med recon, I could do twice as much work. Not to mention AHLTA, but we all feel the same way about that.

I realize that we're only expected to be 3/4ths of a provider in the military, but based upon the tools we have available to us, I think that's still a stretch.

But healthcare would be so much better if we had a single-payer system run by the government...just look at how well the VA functions. No clinic after 2:30? WTF is up with that?!

 

[Perrotfish]

Arguments about socialized medicine aside, I'm really trying to figure out an appropriate middle ground between being lazy (and letting my clinical skills slip) and killing myself for no reward. Right now we see 18 appointments a day on average, five days a week. We do not get an admin half day and most of us junior docs are carrying 3-5 collaterals including one committee chair. The minimum number of appointment slots I need to have is apparently 16 patient per day. On the other hand there are Pediatricians in my Residency class (at other commands) who see as many as 25, and I'm sure my command would be happy to let me do that if I asked. I will never have more than one ccorpsman as support staff and that Corpsman will never have more than three months of training before I have to start working with a new one. So if you were me, how would you arrange your schedule?

 

[BlackFrancis33]

There is no comparison, even if I am supposed to meet the 40%ile MGMA for productivity. I have one exam room (also my office) which I turn over myself, other than the kiosk checking the patients in and a medic getting vitals I do everything else from walking the patient back, giving them directions to the pharmacy, ordering all their labs and meds and arranging their follow-up. I receive all of their questions directly on Relay Health and take care of them myself. When I worked in civilian and private settings for the first time my mind was frickn blown when a nurse checked the patient in, got the medications, and past medical history, and was available to order tests etc after the appointment. Through my residency training and first duty assignment, I really had no idea what an RN actually did in a clinic setting (which is very sad). Every time someone tries to compare us to Cleveland Clinic or some other well funded and staffed system a little bit of me dies inside.

 

[pgg]

Two, maybe three or four. Some days are really busy and I might see 8 or 10, all by myself.

Oh, you said clinic docs. 🙂

 

[Perrotfish]

There is no comparison, even if I am supposed to meet the 40%ile MGMA for productivity. I have one exam room (also my office) which I turn over myself, other than the kiosk checking the patients in and a medic getting vitals I do everything else from walking the patient back, giving them directions to the pharmacy, ordering all their labs and meds and arranging their follow-up. I receive all of their questions directly on Relay Health and take care of them myself. When I worked in civilian and private settings for the first time my mind was frickn blown when a nurse checked the patient in, got the medications, and past medical history, and was available to order tests etc after the appointment. Through my residency training and first duty assignment, I really had no idea what an RN actually did in a clinic setting (which is very sad). Every time someone tries to compare us to Cleveland Clinic or some other well funded and staffed system a little bit of me dies inside.

I'm not quite this badly off. Two exam rooms plus an office, and some clinical support from the nurses blocking the more protocol based Tcons. I do have one full time Corpsman assigned to me and they honestly can get a decent chunk of the hx entered in in addition to the vitals and turning over the room (unfortunately the hx is only useful after they've been with me for a month or two, which is the problem with them leaving every three months). Also it really not fair to compare the remote duty stations to the Cleveland clinic, it should be compared to the in area alternative. The in area alternative to my current MTF has infinitely more problems than we have.

 

[HighPriest]

Two, maybe three or four. Some days are really busy and I might see 8 or 10, all by myself.

Oh, you said clinic docs. 🙂

http://gomerblog.com/2016/05/new-monitor-anesthesiologists/

 

[pgg]

http://gomerblog.com/2016/05/new-monitor-anesthesiologists/

Speaking of clinic ...

http://gomerblog.com/2013/06/398/

 

[Gastrapathy]

I'm not quite this badly off. Two exam rooms plus an office, and some clinical support from the nurses blocking the more protocol based Tcons. I do have one full time Corpsman assigned to me and they honestly can get a decent chunk of the hx entered in in addition to the vitals and turning over the room (unfortunately the hx is only useful after they've been with me for a month or two, which is the problem with them leaving every three months). Also it really not fair to compare the remote duty stations to the Cleveland clinic, it should be compared to the in area alternative. The in area alternative to my current MTF has infinitely more problems than we have.

That's the best supported clinic I've ever heard of for a primary care doc in DoD.

 

[HighPriest]

@Perrotfish :

There are a few answers to your questions, and I have asked myself the same thing many times.

1 - You need to see the bare minimum. This is because the bare minimum is usually pretty bare and because it'll keep the fuzz of your tail.
2 - You want to see volume right out of residency. I kept myself extremely busy during my first two years of work. I promise you that had nothing to do with my desire to be all that I can be for the Army. It was entirely selfish, although I like to sometimes pretend that I was doing a good thing for the MTF and for my patients. They benefitted, to be sure, but I'd be lying if I said I did it for them. (maybe a little for them.)
3 - There is absolutely no reason, beyond your own personal satisfaction or education, to figuratively kill yourself for the military. No one will ever thank you or recognize you for seeing twice as many patients as you're required to see. You will not get promoted, you will not get paid, you will not be thanked by your patients any more than usual, your staff will not appreciate you more, and you will not get into Valhalla based upon that alone. Maybe you'll get a slightly better PCS award if you're a top 10% producer Navy-wide....maybe...and then no one will remember that. Even if your OER says you're super busy, no one cares because clinical medicine is meaningless to the DoD so long as it meets the minimum standard. If anything, busy doctors are a burden to the DoD because they look at you as requiring more support to function, and that's a cost not an income. Guys on the outside stay very busy for two reasons and two reasons only: they get paid more and having available appointment slots is good for marketing. That's it. You are not going to get paid more, and you don't need to advertise.

As a resident, most of have work ethic beaten into us until it's folded into our souls. That's not entirely a bad thing, especially right out of training when your real education begins (and I'm still in that window, don't get me wrong). However, it also means that you become a bit of a masochist. If that is benefitting you, then it is a good thing. Even if the only benefit is that you feel better about yourself. If it is not doing you good, then it is a bad thing. period.

That's just my take, brother.

 

[notdeadyet]

This is a big reason why, IMO, socialized medicine can never work in this country. You can't change human nature. If you pay someone a set salary no matter the volume of patients they see, do you really think that physician is going to go the extra mile?

That'd be a great point, except for the fact that socialized medicine is actually the norm in almost every other industrialized country and works just fine.

 

[idq1i]

That'd be a great point, except for the fact that socialized medicine is actually the norm in almost every other industrialized country and works just fine.

Yup, the upheaval in NHS is clear evidence of it working "just fine."

 

[notdeadyet]

Very fair point, "fine" might be overstatement, but "better than here" wouldn't be. 1/4 of all bankruptcies due to medical bills? Nuts.

There's a reason no one else does it like us. And a reason no one does it as expensively.

 

[Perrotfish]

That's the best supported clinic I've ever heard of for a primary care doc in DoD.

Really? The Pediatricians in my class were sent to 5 separate commands and this seems to be about the standard.

 

[Gastrapathy]

Really? The Pediatricians in my class were sent to 5 separate commands and this seems to be about the standard.

Really

 

[Shikima]

Very fair point, "fine" might be overstatement, but "better than here" wouldn't be. 1/4 of all bankruptcies due to medical bills? Nuts.

There's a reason no one else does it like us. And a reason no one does it as expensively.

What you're talking about are profit margins and stock prices. This is different from the quality of service that is produced here compared to other countries - this is why we're the model for training. If you're boarded here, you'll be accepted into any other country in the world without question. The quality of service, to use NHS as an example, is rationed care. For example, if you have a failing kidney, need dialysis and are over a certain age, you won't get it.

Eliminate the hospital profit model in the US and return to a personal responsibility paradigm, and things would change considerably.

 

[notdeadyet]

This is different from the quality of service that is produced here compared to other countries - this is why we're the model for training. If you're boarded here, you'll be accepted into any other country in the world without question.

Absolutely. We get trained on all the fancy toys and all the new techniques and testing and use all of it liberally because the system is financially invented for the overuse of services to a select group of the public. This makes us well trained. Maybe we are the model for training, but we sure aren't the model for healthcare, as is evidenced by almost no one doing it the way we do it, including countries poorer than us and countries richer than us. And we have more people going bankrupt due to healthcare and dying or having a shortened lifespan from lack of healthcare than almost any other industrialized country.

The "we're #1" thing definitely does not apply to healthcare. Even in countries dealing with healthcare struggles, no one is proposing modeling themselves on us.

But I'll get off the soapbox. Milmed is about the last place you'll find support for universal health care. And it's way off topic here. My bad for biting.

 

[LBB2031]

This thread made me stop and wonder whether there are clinic productivity measures that one has to worry about as a GMO/FS. I have envisioned GMO-land as a place where you man sick call and just try not to kill anybody with your one year of graduate medical education. To that end, I had envisioned that I would be spending a good chunk of my clinic day on UpToDate (or some similar resource) reading about how to manage whatever just walked in the door. But do I also have to worry about efficiency in this role? What level of support should I expect from the corpsman? Will I be taking the vitals and turning the room over myself? How many patients will I be expected to see per day?

The GMO tour is a couple years off for me yet, but it would be nice to know now what level I will need to be prepared to function at when the time comes. Perhaps I can target my preparations accordingly.

 

[jabreal00]

I am a medicine subspecialist. When I was in clinic I saw 15-17 per day depending on no-shows or walkins. I saw a full day of clinic 1 to 2 days a week and half day 1-2 days a week and the other time I was in procedures.